By Eve Purdy (@purdy_eve)
These were the collated key messages from the simulation debrief written on a whiteboard by a consultant trauma surgeon about three weeks ago. The session was an orientation for surgical fellows new to working on the trauma service. Notably missing from this list is any traditional medical content. Even though cases did involve classic decisions about getting to the operating theatre and doing ED thoracotomies, those cases were seen as vehicles to get at the bigger picture discussions– chats about the cultural norms and expectations of the group they were joining. The jot notes left on the white board might seem simple, but they represent a critical shift in understanding around the role of simulation to enculturate new staff. It’s still simulation, just not about the medicine…it’s simulation about who we are, what we value, and how one can belong.
Culture in Trauma Care
In 2019 our team coordinated a collaborative ethnography of trauma teams at Gold Coast University Hospital.  We wanted to understand how trauma teams coordinate their work, and how they might do it better. We confirmed that the complexity of caring for the hyperacute trauma patient is managed through a construct called relational coordination – a combination of shared goals, shared knowledge, mutual respect, and high-quality communication. Guided by our findings, trauma care providers then identified ways to enhance what they do.
One gap was a lack of orientation for surgical trainees starting on the service. While there are similarities to other surgical jobs, some noted in interviews that “there is something just different about trauma” that “took a while to figure out.” When we dug a bit deeper (ok, well not that deep…), we also uncovered some tension between surgical trainees and other groups involved in the provision of trauma care. Conflict centered around key domains of relational coordination. Most often, issues related to shared knowledge of roles and timely communication, both of which impacted mutual respect between groups. Now, two years later, I found myself sitting in a simulation session at a trauma orientation with the new surgeons and the senior surgeons, ED nurses, interventional radiologists, operating theatre nurses, cardiac surgeons, and ED doctors exploring all of the above.
Why at Orientation and Why through Simulation?
Both orientation and simulation activities are moments of cultural compression (times when the values and beliefs of a group are particularly intense).  Both are activities that send strong cultural signals to those joining the group. Planning these activities to incorporate explicit cultural objectives requires groups involved to have above board discussions about who they are, and what they value. This itself is likely beneficial. Then, facilitators can match modalities to objectives. The ultimate hope is that we can then rapidly shape the new members’ understanding of norms within the groups’ they are joining.
For this orientation, our team’s explicit goal was to underscore the importance of shared knowledge about roles, demonstrate our team’s mechanism for communicating shared goals, highlight the importance of timely communication, and to actively foster mutual respect.
Did we succeed?
This question is hard to answer and will require more digging over the months to come. But early evidence in the form of the whiteboard “artefact” suggests that we might have…
Most simply, the whiteboard list exists. For this to have come to be, groups across trauma care (ED, theatre, trauma service, surgical subspecialties, radiology) had to collaboratively plan and attend an activity specifically designed to welcome new trainees. This alone sends a strong signal that we 1) work together and 2) want to support new members of the team.
But if we dissect the contents of the list we can learn even more:
- The team briefing: throughout the simulation activities and debrief we mostly practiced and came back to the importance of team briefings. Explicit communication about name, role, and skills is crucial to success when compiling ad-hoc teams caring for patients under rapidly changing circumstances. Clear prioritization of tasks allows us to accomplish goals. Together we explored exactly how a simple briefing impacts care.  ED nurses and team leaders were able to provide particular insight. This relates directly to “shared knowledge of roles” and “shared goals” and “communication” domains in the relational coordination framework.
- Flexibility in Role: We also found the group discussing how the trauma trainee may end up filling different roles depending on the situation and other skill make-up in the room. Sometimes their primary role will be liaising with surgical services, sometimes it might be doing the primary survey, sometimes they will be doing procedures. This discussion clarified how their role fit into the larger milieu of trauma care, again relating to “shared knowledge of roles”.
- ED Nurses are Skilled and Important: Numerous times throughout the debrief ED nurses were acknowledged by consultant ED physicians and surgeons as being central to the care of the trauma patient. This overt demonstration of mutual respect set the tone for how we view each other’s contributions as integral to the team.
- Consulting Service Buddy: One consultant cardiothoracic surgeon shared his personal challenges working in a different environment than his familiar operating room. He provided insight that pairing up with an ED nurse or registrar may help if you are performing procedures. His vulnerability highlighted that it is all right to ask for help which is related to “mutual respect” and problem-solving based “communication”.
- Call senior staff early: Consulting surgeons from almost every subspeciality involved in major trauma were in attendance. All explicitly commented that they would rather hear about cases early and be involved in decision making from an early stage. This directly relates to timely “communication” that was at the root of some conflict in our prior study.
We don’t yet know whether these messages have actually resulted in organizational cultural learning for the trainees present but I am confident that it has positively impacted relational coordination amongst those involved across the spectrum of trauma care who were involved in organizing the day…and perhaps that is all the evidence we need to do it again next term.
- Purdy EI, McLean D, Alexander C, Scott M, Donohue A, Campbell D, Wullschleger M, Berkowitz G, Winearls J, Henry D, Brazil V. Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care. BMJ open quality. 2020 Feb 1;9(1).
- Purdy E, Alexander C, Shaw R, Brazil V. The team briefing: setting up relational coordination for your resuscitation. Clinical and experimental emergency medicine. 2020 Mar;7(1):1.
- Purdy E. Simulation and Cultural Compression. ICE Blog. March 19 2019.
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